If your Physician prefers to submit a paper form rather than phone Sedgwick with your initial medical certification,
please download this form, complete Part 1 and give it to your Physician to complete and return to Sedgwick.

If you have not recovered or you are not able to return to work on your scheduled return to work
date, and your Physician is unable or unwilling to phone Sedgwick with your extension for disability
benefits, download this extension form, complete Part 1 and give it to your physician to complete
and return to Sedgwick in order to continue your disability benefit payments.

Every new STD/LTD leave request filed with Sedgwick requires this completed form. Please download this form, complete and
sign both sections and return it to Sedgwick immediately. If you complete this form prior to
receiving the form in the mail, please ignore the one you receive in the mail. Sedgwick only
needs one copy of this signed form for our files.

Every new STD/LTD leave request filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return
the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

If your Physician prefers to submit a paper form rather than phone Sedgwick with your initial medical certification, please download this form and immediately give it to the Physician to complete and return to Sedgwick.

Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Every new claim filed with Sedgwick requires this completed form. Please download this form, have the care recipient complete and sign it, and immediately return the form to Sedgwick. If the care recipient completes this form, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

Every new claim filed with Sedgwick requires this completed form. Please download this form, complete and sign it, and immediately return the form to Sedgwick. If you complete this form before receiving the form by mail, please disregard the form you receive by mail. Sedgwick only needs one copy of this signed form on file.

If you're family member has not recovered and you are not able to return to work on your scheduled return to work date; and your family member's Physician is unable or unwilling to phone Sedgwick with your extension for benefits, download this extension form. Complete Part 1 and give it to your family member's physician to complete and return to Sedgwick in order to continue your paid family leave benefit payments.

This form is applicable for employees that have filed for Unpaid leave (FML) to care for a family member who has a serious health condition. Please download this form and have your family member's physician complete it and return to Sedgwick.

This form is applicable for employees that have filed for Unpaid leave (FML) to care for a covered service member who has a serious health condition. Please download this form and have your family member's physician complete it and return to Sedgwick.